2009 Chamberlain Golf Camp Registration

Complete this form and press the SUBMIT button. You will receive an e-mail or phone confirmation within 3-4 days.

Your registration is not considered complete until PAYMENT and the WAIVER FORM are received. The WAIVER FORM is available on-line and may be submitted together with payment. Payment may also be made separately via an on-line banking account. Sorry, we do not accept credit/debit cards.


Please submit a separate registration for sibling campers and/or multiple camp weeks.

Please note: After submitting this form, you may be directed to the QUIA.com website. You can simply CLOSE YOUR BROWSER WINDOW at that time.

Thank you!


A red asterisk (*) indicates required questions.

  1. Camper's Name (Last, First)*


  1. Birth Date (mm/dd/yyyy format)*


  1. School Grade Level in September 2009:*
    K-2
    3
    4
    5
    6
    7
    8
    9
    10
    11
    12


  1. Street Address*


  1. City, ST ZIP*


  1. Primary parent/guardian name (Last, First):*


  1. Parent/guardian e-mail id:*


  1. RE-TYPE parent/guardian e-mail id:*


  1. Home phone number:*


  1. Parent/guardian cell phone number:


  1. Secondary/emergency contact name (can be spouse, relative, friend):


  1. Camp level (see the website for program descriptions):*
    PeeWee ($179/week Mon-Thurs 8am-10am)
    Par-4 ($299/week Mon-Thurs 8am - 12 noon)
    Par-5 ($369/week Mon-Fri 8am - 12 noon)
    Eagle ($459/week Mon-Fri 8am - 1pm)


  1. Secondary/emergency contact phone (preferably cell):


  1. First choice of camp week beginning:*
    Mon, June 29th
    Mon, July 6th
    Mon, July 13th
    Mon, July 20th
    Mon, July 27th NO CAMP
    Mon, August 3rd
    Mon, August 10th


  1. Second (backup) choice of camp week beginning:
    Mon, June 29th
    Mon, July 6th
    Mon, July 13th
    Mon, July 20th
    Mon, July 27th NO CAMP
    Mon, August 3rd
    Mon, August 10th


  1. Payment/registration options:

    (Note: When you are done with this form, click on the [submit answers] button below. You may be directed to the Quia.com website... you can simply close the browser window at that time.)

    You may select one of the following payment/registration options:


    *
    I will print, sign and mail the registration/waiver form and include a check payable to "Chamberlain Golf."
    I will print, sign and mail the registration/waiver form and make a separate payment from my on-line banking checkbook payable to "Chamberlain Golf."